WHO recommendation on intermittent fetal heart rate auscultation during labour

WHO recommendation on intermittent fetal heart rate auscultation during labour

17 February 2018

Recommendation

Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or a Pinard fetal stethoscope is recommended for healthy pregnant women in labour.

(Recommended)

Publication history

First published: February 2018

Updated: No update planned

Assessed as up-to-date: February 2018

Remarks

There is some evidence to suggest that intermittent auscultation (IA) with a handheld Doppler ultrasound device, cardiotocography (CTG), or strict monitoring with Pinard fetal stethoscope could increase the detection of fetal heart rate (FHR) abnormalities, which may in turn reduce hypoxiaischaemia outcomes. However, the impact on other substantive early and long-term infant outcomes is unclear.

The GDG stressed that IA of the FHR during labour is essential for intrapartum care, irrespective if the device used, with strict adherence to clinical protocols. The group noted that monitoring of the FHR during labour is inadequate in many low- and middle-income country (LMIC) settings, and this problem needs to be strongly addressed through quality improvement initiatives in these settings.

The GDG acknowledged the lack of evidence of comparative benefits of different IA protocols and variations in protocols across health care settings. However, the group agreed that standardization of protocol is important for health care planning and medico-legal purposes and, therefore, adopted the following protocol (1).

Interval: Auscultate every 15–30 minutes in active first stage of labour, and every 5 minutes in the second stage of labour.

Duration: Each auscultation should last for at least 1 minute; if the FHR is not always in the normal range (i.e. 110–160 bpm), auscultation should be prolonged to cover at least three uterine contractions. Timing: Auscultate during a uterine contraction and continue for at least 30 seconds after the contraction.

Recording: Record the baseline FHR (as a single counted number in beats per minute) and the presence or absence of accelerations and decelerations.

Regardless of the method used, a clear explanation of the technique and its purpose should be provided to the woman. The findings of the auscultation should be explained to the woman and the subsequent course of action made clear, to enable shared decision-making.

The GDG noted that in some low-resource settings it is common to see faulty equipment, multiple types of equipment (due to donation from different development partners, or procurement from nearby countries) and shortages of batteries and other supplies. Use of equipment that requires electricity can be negatively impacted by power cuts in low-income country settings. Therefore, before switching from Pinard fetal stethoscope to Doppler device, it is important to ensure the appropriate resources are available to sustain implementation.

Background

Globally, approximately 140 million births occur every year (2). The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour (3,4). However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis (5,6). Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth (7). The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies (8).

Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services (9). In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth.

As highlighted in the World Health Organization (WHO) framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes 10).

This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings. In addition to establishing essential clinical and non-clinical practices that support a positive childbirth experience, the guideline highlights unnecessary, non-evidence-based and potentially harmful intrapartum care practices that weaken women’s innate childbirth capabilities, waste resources and reduce equity.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Methods

These recommendations were developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development (11). Briefly, these procedures include: (i) identification of priority questions and outcomes; (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (12) and Confidence in the Evidence from Reviews of Qualitative research (CERQual) (13) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions.

The GRADE evidence-to-decision (EtD) framework (14), an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at two technical consultations in May and September 2017. In addition, relevant recommendations from existing WHO guidelines approved by the Guidelines Review Committee (GRC) were systematically identified and integrated into this guideline for the purpose of providing a comprehensive document for end-users.

Further information on procedures for developing this recommendation are available here.

Recommendation question

For this recommendation, we aimed to answer the following question:

For healthy pregnant women in labour (P), is the use of a particular method of intermittent auscultation for monitoring of fetal heart rate (I), compared with other methods intermittent auscultation (C), more effective and safe for improving birth outcomes (O)?

Evidence summary

Evidence was derived from a Cochrane systematic review that included three RCTs conducted in Uganda, the United Republic of Tanzania and Zimbabwe, involving 6241 women in labour, but only two studies (excluding the one from the United Republic of Tanzania) were included in the metaanalysis (15).

The trial in Uganda (1987 women without risk factors) compared intermittent use of a Doppler ultrasound device with intermittent monitoring using a Pinard fetal stethoscope. Both methods were performed for 1 minute immediately after a contraction, and this was done every 30 minutes in the first stage, every 15 minutes in the second stage before bearing down, and every 5 minutes in second stage when bearing down. The Zimbabwe trial (633 women) was a four-arm trial that compared intermittent cardiotocography (CTG), Doppler and two methods of Pinard FHR monitoring (strict and routine practice). In the CTG arm, an external transducer was applied for 10 minutes every half hour to monitor the FHR; it is unclear how consistently the transducer for contractions was applied. The Doppler and “strict” Pinard methods involved a research midwife auscultating the FHR for 1 minute during the last 10 minutes of every half hour, during and immediately after a contraction, whereas the midwives on duty performed auscultation in the “routine practice” arm. Women in this trial had obstetric or medical risk factors (excluding women with placental abruption or eclampsia) and were booked at or transferred to a referral hospital for childbirth. Where data from this trial were included in meta-analyses, the evidence was downgraded for indirectness. Participants in both trials had term singleton pregnancies with cephalic presentation, and on admission they had cervical dilatation less than or equal to 7 cm and a FHR of 120–160 beats per minute.

Birth experience: There was no evidence on maternal childbirth experience from these trials, including satisfaction, inability to adopt preferred position during labour, or perceived loss of control during labour.

Fetal distress: Low-certainty evidence suggests that a FHR abnormality may be detected more frequently with Doppler than with Pinard auscultation (2 trials, 2598 babies, RR 2.40, 95% CI 1.09–5.29) and that early and late decelerations are probably identified more frequently with Doppler (1 trial, 627 babies, RR 2.72, 95% CI 1.73–4.28) (moderate-certainty evidence).

Perinatal mortality: The evidence for this outcome is of very low certainty. Long-term infant outcomes: These were not reported in the trials.

Additional considerations

The evidence for most outcomes was based on data from a study among women described as having “high-risk” pregnancies. From the evidence, it is uncertain whether increased identification of early and late decelerations and increased caesarean section for fetal distress translate to improved early and long-term infant outcomes.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (16) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that interventions may sometimes be necessary. When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence). They also value receiving care and attention from technically competent health care providers who are sensitive to their needs (high confidence in the evidence).

Additional considerations

The evidence on effects suggests that Doppler in LMICs may increase detection of FHR abnormalities, it probably increases subsequent caesarean section for fetal distress, and it may reduce perinatal hypoxia-ischaemia. Globally, women place a high value on avoiding severe newborn morbidity such as perinatal hypoxia-ischaemia and neonatal seizures and would be willing to have a healthy baby at the expense of increased caesarean section morbidity.

Resources

No research evidence on relative costs or costeffectiveness of Doppler compared with Pinard was found.

Additional considerations

Pinard fetal stethoscope is the cheapest method of IA available.

Equity

No evidence on the impact of different types of fetal monitoring on equity was found.

Additional considerations

WHO’s 2015 State of inequality report indicates that women who are poor, least educated and residing in rural and remote areas have lower access and less health intervention coverage than more advantaged women (17). Studies report that adequate monitoring of labour progress is often lacking in such settings, and that the FHR may only rarely be auscultated (18–20). While Doppler fetal monitors are easier to apply, they are scarce in rural and remote health care facilities as a result of competing health resource needs. The introduction of Doppler monitoring into clinical practice may attract additional costs and therefore its use is more likely in facilities that provide care for more advantaged women.

Acceptability

In a review of qualitative studies exploring women’s experiences of labour and childbirth, results suggest that women would prefer a more hands-on, woman-centred approach to care and are likely to favour any technique that allows for this (high confidence in the evidence) (21). Findings on health care professionals’ experiences of labour and childbirth from the same review (21), show that staff like to use a Doppler device because it offers reassurance and potentially leads to better outcomes for women (compared with CTG) (low confidence in the evidence). In certain settings, health care professionals prefer to use a Pinard fetal stethoscope because it facilitates a more woman-centred approach to care (low confidence in the evidence).

Additional considerations

Qualitative findings from health care professionals were derived from high-income settings only. Doppler also allows a woman to hear the fetal heartbeat, which provides reassurance and could add to its appeal over Pinard fetal monitoring

Feasibility

A qualitative systematic review of women’s experiences of labour and childbirth found no feasibility concerns relating to the use of Doppler (21). The same review also explored health care professionals’ views and found that staff believed that Doppler offers a more flexible approach to fetal monitoring and is less expensive to use compared with other similar monitoring equipment (low confidence in the evidence) (21). However, findings also suggest that in certain low-income settings the resources associated with using Doppler – in terms of initial purchase costs, training and ongoing maintenance – may be restrictive (low confidence in the evidence).

Additional considerations

A Pinard fetal stethoscope is the least expensive option; however, Doppler is probably easier to use and therefore might be more feasible in settings with few midwives if the device is available and if equipment maintenance and a continuous supply of batteries is assured.

Evidence was derived from the four-arm trial conducted in Zimbabwe, which for this comparison involved 633 women and babies. The “routine practice” Pinard group received “usual care” from the midwives on duty. As mentioned above, participants in this study were women with risk factors for complications; therefore, this evidence has been downgraded for indirectness.

Birth experience: There was no evidence on any element of maternal birth experience from this trial, including satisfaction, inability to adopt preferred position during labour, or perceived loss of control during labour.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: Low-certainty evidence suggests that intermittent CTG may reduce hypoxic-ischaemic encephalopathy (HIE) (RR 0.20, 95% CI 0.04–0.90) and neonatal seizures (RR 0.05, 95% CI 0.00–0.89). The absolute difference in HIE based on this limited data set is estimated at 25 fewer per 1000 (from 3 to 30 fewer). Evidence on Apgar scores of less than 7 at 5 minutes is of very low certainty. Cord blood acidosis was not reported in this trial.

Fetal distress: Moderate-certainty evidence suggests that intermittent CTG probably increases the diagnosis of a FHR abnormality (RR 6.08, 95% CI 4.21–8.79), including early and late FHR decelerations (RR 2.84, 95% CI 1.82–4.45). The absolute difference in detecting early and late decelerations based on this limited data set is estimated at 134 more per 1000 (from 60 to 252 more).

Perinatal mortality: Evidence on this outcome is of very low certainty.

Long-term infant outcomes: These were not reported in this trial.

Additional considerations

The evidence for this comparison is based on data from a single study among women described as having “high-risk” pregnancies; therefore, the beneficial effects could be over-estimated. From the evidence, it is uncertain whether increased identification of early and late decelerations, and increased caesarean section for fetal distress, translated to improved early and long-term infant outcomes.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (16) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that interventions may sometimes be necessary. When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).

Additional considerations

The evidence on effects suggests that intermittent CTG in LMICs may increase detection of FHR abnormalities, and may reduce perinatal hypoxia-ischaemia at the expense of subsequent caesarean section for fetal distress. Globally, women place a high value on avoiding severe newborn morbidity such as perinatal hypoxia-ischaemia and may be willing to have a healthy baby at the expense of caesarean section morbidity.

Resources No research evidence on relative costs or cost-effectiveness of different types of IA was found.

Equity No evidence on the impact on equity was found.

Additional considerations WHO’s 2015 State of inequality report indicates that women who are poor, least educated and residing in rural and remote areas have lower access to health intervention coverage than more advantaged women (17). Studies report that adequate monitoring of labour progress is often lacking in such settings, and that the FHR may only rarely be auscultated (18– 20). Electronic fetal monitors are scarce in rural and remote health care facilities as a result of other competing health resource needs. An investment in CTG will likely attract additional costs for the women and for the facilities and therefore its use is more likely in facilities that provide care for more advantaged women. CTG might also reduce equity if it leads to a cascade of interventions that can only be afforded by more advantaged women and those in well-resourced settings.

Acceptability

In a review of qualitative studies exploring women’s and health care providers’ experiences of labour and childbirth, results suggest that some women find the use of CTG reassuring but feel restricted by the equipment and would prefer a more hands-on, woman-centred approach (low confidence in the evidence) (21). From the same review (21), findings show that staff feel CTG is overused and may lead to unnecessary interventions (moderate confidence in the evidence). From a midwifery perspective, staff- believe that CTG undermines traditional, woman-focused skills (moderate confidence in the evidence) and may be used to “babysit” when staffing levels are low (low confidence in the evidence). While some staff- believe that the use of CTG offers reassurance, many do not trust the technology and feel pressured to use it in a defensive manner to temper organizational fears of litigation (high confidence in the evidence). In addition, some health care professionals do not feel sufficiently trained to interpret CTG tracings and acknowledge that understanding and interpretation can be inconsistent (high confidence in the evidence).

Additional considerations

Qualitative findings were derived from HIC settings only. New wireless methods of CTG may be more acceptable to women than existing CTG as they allow women to remain mobile during labour; these methods are undergoing evaluation for use in LMIC settings (22).

Feasibility

Findings from a qualitative systematic review of women’s views and experiences of labour and childbirth suggest that CTG may restrict women’s movement (low confidence in the evidence) (21). The same review explored health care professionals’ views and experiences of labour and childbirth; the findings indicate that many health care professionals believe CTG tends to be overused and might lead to unnecessary interventions (moderate confidence in the evidence). This is likely to have cost implications. Findings also suggest that, where possible, health care professionals prefer to use a Doppler device because of the greater flexibility it allows and because they believe it leads to better outcomes (compared with CTG). In addition, although health care professionals believe that CTG is cheaper to use (compared with other high-tech alternatives), they recognize that financial constraints may lead to poor maintenance and limited availability of accessories in certain contexts.

Additional considerations

These qualitative findings were derived from HIC settings only. A Pinard fetal stethoscope is likely to be the cheapest option in low-resource settings. The need for ongoing maintenance and supplies with CTG reduces its feasibility in LMICs.

Evidence for this comparison was derived from the Zimbabwe trial that included women with risk factors for complications (1 trial, 625 women and babies); therefore, it has been downgraded for indirectness.

Birth experience: There was no evidence on maternal birth experience from this trial, including satisfaction, inability to adopt preferred position during labour, or perceived loss of control during labour.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: Evidence on Apgar scores less than 7 at 5 minutes, neonatal seizures and hypoxic-ischaemic encephalopathy (HIE) is of very low certainty.

Fetal distress: Moderate-certainty evidence suggests that intensive Pinard monitoring probably increases the diagnosis of a FHR abnormality (RR 1.71, 95% CI 1.10–2.65), but may not do so for early and late FHR decelerations (RR 1.33, 95% CI 0.79–2.23) (low-certainty evidence).

Perinatal mortality: Evidence on this outcome is of very low certainty. Long-term infant outcomes: These were not reported in this trial.

Additional considerations

From the evidence, it is uncertain whether increased identification of a FHR abnormality leads to improved birth and long-term infant outcomes.

Values Findings from a review of qualitative studies looking at what matters to women during intrapartum care (16) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that medical intervention or assessment may sometimes be necessary. Where this is the case, they would like to receive relevant information from technically competent health care providers who are sensitive to their needs (high confidence in the evidence).

Resources

No research evidence on resources was found.

Additional considerations

The two study arms in the Zimbabwe study appear to reflect research-context (rigorous) practice versus typical daily (less-rigorous) practice. It is plausible that more rigorous fetal monitoring is more resource intensive in terms of staff time.

Equity

WHO’s 2015 State of inequality report indicates that women who are poor, least educated and residing in rural and remote areas have lower access to health intervention coverage than more advantaged women (17). In these settings, it is likely that FHR monitoring is less rigorous due to a lack of resources and poor quality of care. Studies report that adequate monitoring of labour progress is often lacking in such settings, and that the FHR may only rarely be auscultated (18–20). Addressing this fundamental quality of care issue with appropriate training, supervision and monitoring could have an impact on equity, irrespective of the method of intermittent auscultation.

Acceptability Findings from a qualitative systematic review of women’s and providers’ experiences of labour and childbirth (21) indicate that women are likely to appreciate the more intimate connection with a health care professional that this strict or intensive monitoring approach enables, provided the practice is conducted by kind, competent staff who are sensitive to their needs (high confidence in the evidence). The review’s findings also suggest that health care professionals like to deliver this kind of woman-centred care provided there are enough resources (staff) to cover the more labour-intensive nature of this approach (high confidence in the evidence).

Additional considerations The qualitative evidence above suggests that if fetal monitoring were to be performed, women would prefer that competent staff perform it in such a way such that it detects fetal hypoxia in time to avert poor outcomes (21). Women may feel that they are better looked after if their health care providers are providing strict monitoring of the well-being of their baby.

Feasibility A qualitative systematic review of women’s experiences of labour and childbirth found no feasibility concerns relating to the intensive use of Pinard fetal stethoscope. The same review also explored health care professionals’ experiences of providing intrapartum care and found that staff sometimes lacked the time to conduct monitoring using this approach and felt that accurate monitoring required skill and experience that was sometimes difficult to achieve in time-pressured situations (low confidence in the evidence) (21).

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

The successful introduction of evidence-based policies related to intrapartum care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.

The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.

An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.

Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

Health policy considerations

A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.

To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages.

To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.

To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

Organizational or health-system-level considerations

Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.

Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible.

Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools.

The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labour).

Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For health care facilities without availability of caesarean section, context- or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop.

Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient.

Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies.

Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities.

Behaviour change strategies aimed at health care providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched.

Successful implementation strategies should be documented and shared as examples of best practice for other implementers. User-level considerations

Community-level sensitization activities should be undertaken to disseminate information about:

respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities;

The state of the world’s children 2016: a fair chance for every child. New York (NY): United Nations Children’s Fund; 2016 (https://www.unicef.org/ publications/files/UNICEF_SOWC_2016.pdf, accessed 20 October 2017).

Resources

Guideline

This up-to-date, comprehensive and consolidated guideline on essential intrapartum care brings together new and existing WHO recommendations that, when delivered as a package, will ensure good-quality and evidence-based care irrespective of the setting or level of health care. The recommendations...

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